Welcome to the Resilience House Application Process!

Please fill out all fields to guarantee your application is received.

First name: Client first name

Last name:Client last name

Email:Client email

Phone:Client phone

Birthdate: Client birthdate

Age: Text field

Please fill out the emergency contact information below:

Contact

Who referred you?

Referral: Text field

Current Treatments Completed: Paragraph

Anticipated Admit Date: Date

Recovery Residence History: Paragraph

Please choose all substances of choice that apply:

Client substances of choice

RecoveryHistory

Do you have a vehicle? Text field

Do you have a valid driver's license? Text field

What goals are you trying to achieve in your time at Resilience House, if you are accepted?Paragraph

Are you diagnosed with any medical or mental health condition, other than substance use disorder? If yes, are you receiving treatment for these conditions?

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If any, what medications are you prescribed?

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Do you have a history of self-harm? Text field

If yes, do you have any recent suicidal ideation? Text field

Relationship Status? Text field

Do you have any children? Text field

Are you employed? Text field

If not, what is your work experience and plan?

Paragraph

Have you ever been arrested, convicted, or questioned for arson, any violent or sexual crimes?

Paragraph

Any legal issues? Probation or Parole? If yes, explain below and fill out the PO information:

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Probation

Anything else you would like us to know?

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